Commitment for commissioners in heath, social care and GP commissioning 1. Improving the quality and experience of care for people with dementia (and their carers), by commissioning a whole systems approach to dementia 2. Ensure through effective evidence-based commissioning, we support providers to minimise the need for antipsychotic drugs, and in addition to ensure prescribing is in line with NICE guidelines across the health and social care system. Needs Assessment Joint Strategy Needs Assessment and Health & Wellbeing Strategy (and wider strategic plans) demonstrate the needs of people with dementia and carers by including residential care standards, workforce capacity & capability, health promotion and prevention and safeguarding protocols. Needs Assessment/Priority setting All localities to take local audits (using available/shared audit tools) of current practice for antipsychotic prescribing medication for people with dementia which covers the whole health and social care system by 31st March 2012 Commit to change local commissioning plans as appropriate and contracts with all partners to reflect this and to reduce antipsychotic prescribing. Measured by: the lens of people with dementia and their carers professional behaviours/practice actions at an organisational/system level. Commissioning specifications and contracts which reflect interventions and functions which deliver outcomes which minimize the need for anti-psychotics. Service review/priority setting Ensure local plans are in place by 31/3/12 to deliver the national dementia strategy specifically anti psychotic prescribing. Publicize and promote this plan and ensure is accessible and understandable by the public. Commissioners to make dementia business as usual across all areas of commissioning. Commissioners to develop and enhance leadership and governance for prescribing. Commissioning pack to include SCIE recommendations. Recommended reading/information prescriptions (see appendix 1). Audit results and statistics with examples and key questions to ask of the audit data e.g. % prescriptions generated in secondary care, no of pts on antipsychotics with no diagnosis, what % people in care homes have had no review in last 6 months, what are prescribing stats in primary care, what is the incidence of falls reported from people with dementia on antipsychotics. Examples of good practice include: SE Collaborative audit and quality indicators Surrey whole systems model inc Telecare. Local and national publications (see appendix 1). Dementia portal/nhs Networks dementia section This is me Alzheimer's society Misspent opportunities audit commission.
Commitment for commissioners in heath, social care and GP commissioning continued... 1. Improving the quality and experience of care for people with dementia (and their carers), by commissioning a whole systems approach to dementia 2. Ensure through effective evidence-based commissioning, we support providers to minimise the need for antipsychotic drugs, and in addition to ensure prescribing is in line with NICE guidelines across the health and social care system. Service redesign and supplier side reshaping Enabling providers with MDT to use appropriate alternatives to prescribing by strong evidence based commissioning in all areas (this is the primary responsibility of the doctors but a part of the commissioning ethos). Ensure in reach services appropriate to your locality is a priority within commissioning intentions. Incorporate within primary, acute, mental health and care home contracts governance mechanisms for regular audit of anti-psychotic prescribing. Implement NICE compliant protocols between primary and secondary care for the review of anti-psychotic medication on patient transfers. Clinical Decision making Monitor and implement an MDT and multi-agency process for serious untoward incidents associated with people with dementia and their carers. Workforce development Education commissioned for the public, workforce and managers enabling each to gain key skills to improve outcomes. Setting key educational stds for people in the health & social care, independent sector workforce, working with people with dementia. Enabling provision of training for lay carers. Compendium of good practice and success stories/case studies, including those alternative approaches. Set up a steering group to share good practice. Create a central place to collate information National Field or dementia portal. Reference and link to websites which contain to partnerships, protocols for good practice. Local QOF data with up to date information Link to QIPP and QOF data/les CQuINs. CQC. Link to specific web pages and key documents which support commissioning decisions.
Commitment for general practitioners and primary care teams GPs commit to identify and review their patients who have dementia and are on antipsychotics with the purpose of understanding why antipsychotics have been prescribed. Working in partnership with the person with dementia, their family and carers and their medical colleagues in psychiatry to establish whether or not the use of antipsychotics is inappropriate and whether or not it is safe to begin the process of discontinuing their use and to establish that access to alternative interventions can be secured. Undertake audit of accuracy of practice registers. And review of prescribing decisions. Identify who is on repeat prescriptions and review timescales in place. Develop an understanding of the alternatives, the evidence base for these and their availability locally. Put referral processes in place- e.g. memory clinics. Work in partnership with other colleagues (psychiatrists, pharmacists, care home leaders) to develop a mutual understanding of the existing issues and develop a planned review for people with dementia who are on antipsychotics to include specific support around the withdrawal of antipsychotics. Work in partnership with other colleagues (psychiatrists, pharmacists, care home leaders) to develop a mutual understanding of the existing issues and develop a planned review for people with dementia who are on antipsychotics to include specific support around the withdrawal of antipsychotics. Discuss patients/families/carers expectations around prescribing what people think they want. National standards & recommendations for review and withdrawal of antipsychotic drugs and non-pharmaceutical alternatives. Guidelines for Care Homes and Nursing Homes (example from Medway) & Skills for Care guidance. Awards for good practice including Cornwall STAR (challenging antipsychotics and commissioning in dementia, via Martin Freeman martin.freeman@glos.nhs.uk). Prescription guidelines authored and owned by all partners (example available from Medway achild@nhs.net). Link with the Coroner s office- avoidable deaths. Script switch messages for use in practicesprescribing software and AP alerts. Using practice based communications- leaflets, RCGP good practice with carers.
Commitment for general practitioners and primary care teams continued... GPs commit to identify and review their patients who have dementia and are on antipsychotics with the purpose of understanding why antipsychotics have been prescribed. Working in partnership with the person with dementia, their family and carers and their medical colleagues in psychiatry to establish whether or not the use of antipsychotics is inappropriate and whether or not it is safe to begin the process of discontinuing their use and to establish that access to alternative interventions can be secured. Audit who is on Aps: diagnosis under review. At risk: care plan for people at risk appropriate use of medicines and alternatives focus on admission prevention. Communication: secondary care at discharge-identifying post discharge support improved information in community regarding relevant life history to know the pt primary to secondary care passport. Environment/co-working. Resources and mapping of non-pharmacy alternatives. Use of personal budgets. Business case development for investment in alternatives for commissioners. Pharmacy/non pharmacy interventions Holistic assessment carers/families Predictive modelling. Appraisal revalidation QoF Qipp CQuin. Carers/families questionnaire Hospital Passport Reminiscence. Community Matrons Medicines Management Team Admission prevention teams Third sector Social services. Holistic assessment -Interia project. Map of medicine.
Commitment for hospital doctors and multidisciplinary teams carefully considering whether or not a prescription for antipsychotic medication is appropriate for someone with dementia who is in hospital and to review the prescription on transfer or discharge from hospital to another setting. Increase understanding & awareness of dementia & delirium, leading to better diagnosis. Develop an understanding of alternative interventions and how to use these. Use care pathways for people with dementia in acute hospital settings. Use a case management approach. Use the person centred plan (This Is Me). NO discharge or transfer without medication review. NICE Guidelines. NSF-guidance on medication review. Psychological alternatives for acute settings. Psychological alternatives for care homes. Alzheimer s Society work via Jane Fossey - Jane.Fossey@oxfordhealth.nhs.uk Http://alzheimers.org.uk/site/scripts/document s_info.php?documentid=77&pagenumber=5 Undertake benchmarking. BNF Education and training from induction for Nurse and Junior Drs. Guidance from faculty of old age psychiatry=rcgp LINK.
Commitment for hospital doctors and multidisciplinary teams continued... carefully considering whether or not a prescription for antipsychotic medication is appropriate for someone with dementia who is in hospital and to review the prescription on transfer or discharge from hospital to another setting. Clarify role of Acute Trust Dementia lead and link to Chief Nurse. Community wide MDT meetings with Care Homes with Acute Hospital Geriatrician, Psychiatrist, GP,Pharmacist and care home lead. Geriatricians have a core role in influencing other specialties within the Hospital. Work with Trust Drug and therapeutic committees and see antipsychotic medication review as part of current working practice of wider medication review. Delirious about dementia-bgs website. (duncan.forsyth@addenbrookes.nhs.uk). British association of occupational therapists and College of occupational therapy- Special interest forum for people with Dementia & practice guidance http://www.cot.co.uk/ Royal college of nursing dementia forum. Consider coding of people with dementia. Induction process and appraisal. Add AP prescribing to organisational risk register/corporate governance. Every member of MDT has had basic awareness training about supporting a person with dementia in an acute hospital setting. Every person with dementia who is admitted to an acute setting has had an assessment that includes cognitive function, delirium & current medication. All members of the hospital MDT are aware of which drugs are antipsychotics and how these may affect a person with dementia. Any prescription for antipsychotics issued in an acute setting triggers a response from hospital pharmacy and is a time limited prescription.
Commitment for leaders of care homes identifying all people prescribed antipsychotic medication and to documenting and delivering an evidence-based, personalised care-plan developed in partnership with the individual, their family & the multidisciplinary clinical team. Review processes and infrastructure which may lead to inappropriate prescription of antipsychotics and put in place other systems to support best practice (See slide 2: Sub-themes for action arising from this). Develop/put in place a proactive, systematic register for maintaining and monitoring all antipsychotic prescriptions, reviews and outcome decisions. Undertake a home-wide review of prescriptions initially & then establish a system of proactive review for all new residents, upon taking up residence, and thereafter in line with current clinical/best practice guidelines. Establish clear relationships with, and links in to, emerging collaborative partnerships between GPs and Pharmacists - establishing as part of the wider call to action. Develop clear, systematic protocols to ensure support to care home staff in actively challenging antipsychotic prescribing. National Dementia Strategy Guidelines from Alzheimer s Society Guidelines from Dementia Alliance NICE and SCIE Guidelines. Multi-disciplinary care pathway: management of challenging behaviour. Department of Health: compendium of best practice (Examples of non-drug alternatives) BUPA Mental Capacity Act postcard for staff. SCIE Dementia Gateway Social Care TV Charities Websites Social Media (e.g. Facebook): BUPA, Dementia UK, possibly others. Develop clear, systematic information resources & support for use by the individual, their family and care home staff. Provide access to dementia-specific training & development opportunities for all care home staff. Care UK: Experiential Learning Course (Surry Pilot) BUPA: How to work with challenging individuals BUPA: Understanding behaviour (partnered with Bradford University) Alzheimer s Society: Focused Intervention Training for Staff (FITS 10-day programme) Boots: Dementia Medication Training ElBox, SKIP, MABO, Studio 3 & Edge.
Commitment for leaders of care homes continued... Key Theme for Action Sub-themes for action Resources/sources of help Review processes and infrastructure which may lead to inappropriate prescription of antipsychotics and put in place other systems to support best practice. Identify a named Dementia Champion in each care home, supported through appropriate specialist education and training, with sufficient authority to effect change. Identify and utilise personal information resources for use by the individual, their family and care home staff. Provide the times and resources for recognised accredited training on good dementia care. Build relationship with the community to put in place interventions in the care home in line with best practice. Provide ongoing training and support to staff. Tools to help in the care environment e.g. Dependency scoring template Flowchart for recognising problems which could change behaviours Observational tools SCIE website, gateway &social care TV. Training resources e.g. Training DVDs Resident experience training Motivational mapping tools Voluntary sector - Alzheimer s Society training and resources E-learning resources Medicines management training. Establish and maintain a clear relationship with multidisciplinary team members (e.g. GPs and pharmacists). Sources of support/service other than antipsychotics e.g. Alternative therapies and activities Local memory clinics Environmental resources - e.g. Eden Journal of dementia care. Health and social care professional support. Care plan. The individual, their family and carers e.g. This is me document/dementia passport. Examples of good practice e.g. Nothing ventured, nothing gained DH doc DH Compendium of best practice.
Commitment for pharmacists reviewing the people under my care to identify those who are prescribed antipsychotic medication and to work in partnership with my prescribing and other health care colleagues to review each individual by 31st March 2012. Establish a clear dialogue and agree joint working practices for reviews with all prescribing partners. Become better informed about best practice guidelines for the prescribing of antipsychotic medication, and alternative interventions, for people with dementia. Provide support and sign-posting to alternative resources for people with dementia and their carers. Community pharmacists: Query every prescription for an antipsychotic for people aged 65 years or over and/or those known to have dementia and search for, and audit, all people 65 years and over who have received antipsychotic medication in the last 3 months. Guidance in Bannerjee report Source of specific guidance from RCGP. http://www.rcpsych.ac.uk/files/pdfversion/cr 138.pdf http://www.rcpsych.ac.uk/files/pdfversion/cr1 19.pdf (see section 8 and appendix). Guidelines from Alzheimer s Society Guidelines from Dementia Alliance Talking with people with dementia and their families. Hospital pharmacists: Query every prescription for an antipsychotic for people aged 65 years and over and ensure that discharge information is up to date regarding the actions GPs should take (in line with NICE guidelines). All antipsychotic are flagged on transfer documentation with a clearly identifiable review date PCT and commissioning pharmacists: Include antipsychotic within QOF action plan and QIPP target. Review/challenge high prescribers. Report back on my progress in these activities. NICE and SCIE guideline. Multi-disciplinary care pathway management of challenging behaviour in dementia. Department of Health compendium of best practice. (Examples of non-drug alternatives).
Commitment for psychiatrists and mental health teams review the causes(s) of disturbed behaviour before initiating or continuing antipsychotic treatment. To challenge routine practice and update knowledge base using current evidence and best practice. Utilise clinical governance esp. clinical audit, to provide information on local practice to inform required local action. NICE guides for dementia Royal College Psychiatrists resource pack. Getting to Know You charts to help identify causes of disturbed behaviour. Offer local education opportunities to all psychiatrists and to all hospital doctors. Increase links and offer educational support to Care Homes e.g. 1 day conference with input from psychiatrists and care homes staff. Increase links with local GPs esp. identifying and working with GP 'dementia leads to review local practice. Annual mtg of Faculty of Old Age Psychiatrists/ Royal College (March mtg but could utilise newsletters). Flowchart for identifying causes of BPSD Anne Child. a.child@nhs.net RAGE for monitoring. Joint visits (psychiatrist and GP) to struggling care homes (possibly monthly). Patients discharged on antipsychotic treatment to have a clear management plan and support from the Care Home liaison team. Admission process pathway North Staffs (audit data to demonstrate benefits).
Commitment for people with dementia, their carers and families proactively seeking a conversation with my (our) GP to review care and agree a personalised care plan (in line with best practice). Seek information and support from the voluntary sector and other resources on treatment and care options and seek guidance on how to establish a dialogue with health and social care professionals. Take responsibility for sharing insights into who I am and what I want (who the person I care for is and what they want) to support the development and implementation of an effective, valuable and realistic care plan. Take responsibility for working in partnership with care team to ensure initial and ongoing appropriate review of the care plan. Care plan and who I am document (e.g. This is me, Dementia Passport). Information from the voluntary sector (e.g. Alzheimer s Society s antipsychotics booklet, Alzheimer s Society website, Age UK website). Local services and peer support networks (e.g. Memory clinic, dementia adviser, support group). Information from membership organisations such as UKHCA and ECCA. Non-web information sources (e.g. Alzheimer s Society help lines, libraries). Local and national media. Health and social care professionals (e.g. GP, CPN, consultant).